Provider Demographics
NPI:1457841629
Name:VIJAYALAKSHMI JESSON DDS PC
Entity Type:Organization
Organization Name:VIJAYALAKSHMI JESSON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:VIJAYALAKSHMI
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGAMUTHU JESSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-990-3697
Mailing Address - Street 1:10820 RHODE ISLAND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-2570
Mailing Address - Country:US
Mailing Address - Phone:301-937-9330
Mailing Address - Fax:301-477-4831
Practice Address - Street 1:10820 RHODE ISLAND AVE STE A
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705
Practice Address - Country:US
Practice Address - Phone:301-937-9330
Practice Address - Fax:301-477-4831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12246122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1144211046Medicaid